Innisfree Health and Rehab, LLC

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review and interviews, the facility failed to notify an emergency contact of an unstageable pressure ulcer in a timely manner for one (Resident #88) of two residents reviewed. The findings including: Review of Resident #88's admission Record revealed the facility admitted Resident #88 on 04/01/2025 with an original admission date of 09/26/2024. The admission Record revealed Resident #88 had diagnoses that included unstageable pressure ulcer with an onset date of 05/23/2025 and admitting diagnoses of diverticulitis with perforation, and ischemic cardiomyopathy dated 04/01/2025. Review of admission Minimum Data Set (MDS) with an Assessment Reference Date of 04/07/2025, revealed Resident #88 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure a resident was free from physical and verbal abuse for one (Resident #37) of four residents reviewed.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, record review and interview the facility failed to appropriately monitor and supervise a resident with severe cognitive impairment to prevent elopement for one (Resident #91) of one residents reviewed.

Inspectors wroteThrough observation and interview the facility failed to post the results of the most recent survey of the facility in a place readily accessible to residents, family members and legal representatives of residents.

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to ensure the care plan was updated to include contracture and contracture management for 1 resident (Resident #13) of 1 resident reviewed for positioning and mobility and contracture management.

Inspectors wroteBased on observations, interviews, and facility policy review, it was determined that the facility failed to remove two bottles of expired tube feeding from current stock for 1 of 1 medication room and failed to label two insulin vials and three inhalers with open dates when the manufactures seal was broken in 2 of 2 medication carts reviewed for medication storage.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure meals were prepared in a method that maintained an appearance that was acceptable to the residents to encourage good nutritional intake for 2 of 2 meals observed.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure dietary staff changed gloves and washed their hands before handling food items and clean equipment when contaminated; food items stored in the refrigerator and freezer were covered, sealed, and dated; expired food items were promptly removed/discarded on or before the expiration or use by date.

Inspectors wroteBased on observations, interviews, record review, facility document review, facility policy review, it was determined that the facility failed to properly store oxygen tubing and Continuous Positive Airway Pressure (CPAP) tubing and mask for 2 (Resident #13-oxygen tubing and Resident #52-CPAP tubing and mask) of 2 residents reviewed for Infection prevention and control of equipment or devices.

Inspectors wroteThrough observations, record review, and interviews the facility failed to ensure residents were able to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from their bed. This affected 4 (Residents #5, #24, #84, and #250) of 19 sampled residents.

Inspectors wroteBased on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to provide written bed hold notice for 1 (Resident #97) of 1 resident reviewed for hospitalization.

Inspectors wroteBased on observations, interviews, and record reviews, it was determined that the facility failed to ensure oxygen was on the care plan for 1 (Resident #28) of 1 sampled resident.

Inspectors wroteBased on observations, interviews, record review, facility document review, it was determined that the facility failed to ensure the resident was provided hand roll for contracture management for 1 (Resident #13) of 1 resident reviewed for providing contracture management.

Inspectors wroteBased on interviews and record review the facility failed to ensure 1 (Resident #42) of 5 sampled residents that were reviewed for unnecessary medication did not have an order to receive a PRN (as needed) medication past 14 days without justification, and an evaluation by the doctor.

Inspectors wroteBased on observations, interviews, and record reviews, it was determined that the facility failed to ensure a device to help keep food on a plate while eating was available for 1 (Resident #42) of 1 sampled resident who required adaptive equipment for meals.

Inspectors wroteBased on interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to send home health referrals prior to discharge for 1 (Resident #200) of 2 residents reviewed for discharge process.

Inspectors wroteBased on observation and interview, the facility failed to ensure the planned written menu was followed to ensure the nutritional requirements were met for all residents who received their meal from one of one kitchen.

Inspectors wroteBased on observation and interview the facility failed to ensure that cooking utensils were stored properly, that food items were sealed and dated upon entry into the kitchen and upon opening, that hands were washed, and gloves changed to prevent cross contamination/possible food borne illness during preparation and dining and hair covers were used in the kitchen. The failed practice had the potential to affect 85 residents who receive their meals from 1 of 1 kitchen according to a list provided by the administration on 11/17/23 at 10:02 AM.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure 2 (Residents #14 and #51) of 2 sampled residents were treated with dignity by standing over the resident while providing feeding assistance and referring to the resident as a feeder in front of the resident and three other residents for (Resident #14); and administering an insulin injection while the resident was seated in the dining area for (Resident #51).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received nail care/personal hygiene to promote good personal hygiene and grooming for 2 (Residents #14 and #22) of 2 sample mix residents who were dependent on staff for nail care and personal hygiene.

Inspectors wroteBased on observation and interview, the facility failed to ensure food items prepared for residents with a physician order for a pureed diet received food that was the appropriate consistency to promote consumption and minimize the risk of choking. The failed practice had the ability to affect 3 of 3 (Residents #14, #41 and #44) sampled residents who had a physician's order for a pureed diet and received their meals from 1 of 1 kitchen according to a list provided by the Assistant Administrator on 11/17/23 at 8:45 AM.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure hand hygiene and infection control measures were implemented during medication administration and during activities of daily living (adl's) to prevent potential infections for 2 (Residents #14 and #30) of 2 sampled residents.

Inspectors wroteBased on observation and interview, the facility failed to provide assistive devices necessary to maintain the highest level of independence and dignity for 1 (Resident #69) of 1 sampled resident who required a handled cup for hydration.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure respiratory care, was consistent with professional standards of care as evidenced by their tubing not being stored in a bag or other closed container when not in use to prevent potential contamination for 2 (Resident #5 and #40) of 7 of 7 (Resident #1, # 5, # 27, # 40, # 50, # 55, and # 108) sample residents reviewed. This failed practice had the potential to affect 13 residents who had physician orders for oxygen, according to a list provided by the Director of Nursing (DON) on 08/17/22 at 10:47 AM.